Sample Psychotropic Medication Policy and Procedure May Also Be Used To Improve Care to Dementia Residents The following attached tools are available on the CMS Advancing Excellence website www.nhqualitvcampaign.org 1. Sample Psychotropic Medication Policy and Procedure 2. Sample Psychopharmacologic Interdisciplinary Medication Review 3. Provider Checklist Suggestions for Improving Dementia Care in Nursing Homes 4. Questions to Consider in Interdisciplinary Team Review of Dementia Care Cases 5. Self-Assessment State Coalition Provider Question Worksheet 6. Provider Dementia Care Implementation Flow Diagram Developed under the Partnership to Improve Dementia Care in Nursing Homes
Sample Psychotropic Medication Policy and Procedure Shared with Permission of Karyn Leible, RN, MD, CMD Policy: Physicians and mid-level providers will use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. Standards: 1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. 2. The facility supports the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness. 3. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident. 4. The facility supports the goal of determining the underlying cause of residents having difficulty sleeping so the appropriate treatment of environmental or medical interventions can be utilized prior to psychopharmacologic medication use. 5. Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation. 6. Psychopharmacological medications will never be used for the purpose of discipline or convenience. 7. Psychotropic medications include: anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs.
Responsible Party Actions Required: Primary Care Physician, PA or APN 1. Orders for psychotropic medication only for the treatment of specific medical and/ or psychiatric conditions or when the medication meets the needs of the resident to alleviate significant distress for the resident not met by the use of non-pharmacologic approaches. 2. Documents rationale and diagnosis for use and identifies target symptoms. 3. Documents discussion with the resident and/or responsible party regarding the risk versus benefit of the use of these medications included in the discussion and documentation must be the presence of any black box warning or off label use of the medication affecting the prescribing of the medication to the resident. 4. Evaluates with the interdisciplinary team, effects and side effects of psychoactive medications within one month of initiating, increasing, or decreasing dose and during routine visits thereafter. 5. Monitors the resident for lack of drug efficacy clinically and in discussions with the interdisciplinary team within one month of initiating and during routine visits. 6. Attempt a gradual dose reduction (GDR) decrease or discontinuation of psychotropic medications after no more than 3 months unless clinically contraindicated. Gradual dose reduction must be attempted for 2 separate quarters (with at least one month between attempts). Gradual dose reduction must be attempted annually thereafter or as the resident's clinical condition warrants. 7. Sedative/ hypnotics will be reviewed quarterly for gradual dose reduction. GDR must be attempted quarterly unless clinically contraindicated. 8. Orders for PRN psychotropic medications will be time limited (i.e., times 2 weeks) and only for specific clearly documented circumstances. 9. Obtains psychiatric consultation as resident's clinical condition requires.
Psychiatrist/mental health (When available to a facility) 1. May assist the facility in establishing appropriate guidelines for use, dosage and monitoring of psychotropic medications. 2. Uses the above standards (1-9) in recommendations to physicians. 3. Provides in service training to nursing, medical, and other staff as appropriate. 4. Is available for consultation. 5. Helps develop behavior management plans. Nursing 1. Monitors psychotropic drug use daily noting any adverse effects such as increased somnolence or functional decline. 2. Will monitor for the presence of target behaviors on a daily basis charting by exception (i.e., charting only when the behaviors are present). 3. Reviews the use of the medication with the physician and the interdisciplinary team on a quarterly basis to determine the continued presence of target behaviors and or the presence of any adverse effects of the medication use. 4. AIMS will be performed on any resident on and antipsychotic on a quarterly basis changes will be reported to the physician. 5. May develop behavioral care plans. Social Services 1. Maintains a list of residents in the facility on psychoactive medications. 2. Coordinates the interdisciplinary team resident reviews of psychoactive medications. 3. May develop behavioral care plans. Pharmacist and/or consulting pharmacist 1. Monitors psychotropic drug use in the facility to ensure that medications are not used in excessive doses or for excessive duration. 2. Participates in the interdisciplinary quarterly review of resident's on psychoactive medications. 3. Notifies the physician and the nursing unit if whenever a psychotropic medication is past due for review.
Medical Director 1. Reviews psychotropic medication policy with the interdisciplinary team at least annually. 2. Monitors the overall use of these medications in the facility through the QAPI process. 3. Identifies any resident care or potential regulatory issues with the use of psychotropic medications in the facility and discusses with the medical staff as appropriate. 4. Participates in the interdisciplinary quarterly review of resident's on psychoactive medications and facilitates communications with attending physicians of any recommendations from the IDT.
Psychopharmacologic Interdisciplinary Medication Review Shared with Permission of Karyn Leible, RN, MD, CMD Resident: Date of review: Reason for Review: Initiation Dose reduction consideration Dose reduction review Change in condition Diagnosis for psychopharmacologic medication use: Other diagnosis: Medication to be reviewed: Date started Last review Last GDR attempt Other Medications: Target behavior/symptom Decline in frequency No longer present No change Target symptom/behavior non-pharm interventions present in care plan Documentation of effectiveness Evidence of adverse effects or functional decline: Falls Increased assistance for ADLs Somnolence Weight loss Decreased oral intake (fluids) Decreased mobility Insomnia Restlessness Other: Recent Pain Assessment Recent sleep study (if indicated) AIMS Date Score PHQ 9 Date Score BIMS Date Score Pertinent laboratory studies: Risk/benefit discussion with resident or MDPOA documented at initiation of medication: Date
Committee Recommendations: Response: Practitioner Signature and date: Committee Members:
Partnership to Improve Dementia Care in Nursing Homes Suggestions for Provider Checklist % of residents in facility on atypical antipsychotics: Quality Measure State Percentile Rank antipsychotics: Staff in all departments, are trained in person-centered care and how to respond effectively to behaviors (access sample training programs on Advancing Excellence website; Hand in Hand). In addition to medical and psychiatric history, recent changes in behavior or cognition and other standard clinical evaluations, at admission information is obtained from the resident, family, and/or caregivers on the resident's preferences, routines, pre-dementia personality, social patterns, responses to stress and effective interventions. The information obtained on during the admission process is conveyed to direct caregivers. This admission information is integrated into the care plan and may be revised over time as the resident's condition and needs change. Interviews with staff demonstrate that they have implemented and are following the care plan, continue to seek input from family members or care givers for unresolved issues, and communicate with practitioners regarding change in condition or new or persistent symptoms. If a resident is placed on an antipsychotic medication, there is documentation in the record that the resident or appropriate legal representative was involved in the decision. Facility has consistent staff assignments (same Certified Nursing Assistant to same resident 5 days/week). Certified Nursing Assistant to Resident Ratio 1 st shift/2" shift/3`d shift Senior leadership (Nursing Home Administrator, Director of Nursing, Medical Director) attend care plan meetings periodically for residents with unresolved behavioral or psychological symptoms of dementia. Interdisciplinary team seeks input at care plan meetings from the Medical Director, Consultant Pharmacist and Certified Nursing Assistants for residents with behavioral or psychological symptoms. Providers conduct outreach and education to the resident's family and strongly encourage their participation in care plan meetings (offering to flex the schedule or use conference calls when the family cannot physically be in attendance). Nursing Home Administrators and Directors of Nursing review quality measures (e.g., monthly) and use the Quality Measures report to identify residents who may need alternative interventions and oversee their implementation. Each month, Nursing Home Administrators and Directors of Nursing review Quality Measures report, along with the Pharmacy Consultant report, to identify residents appropriate for possible reduction/elimination of antipsychotics. The review of aggregate data should be combined with real-time, case-based information and input from practitioners. Nursing Home Administrators and Directors of Nursing review Pharmacy Consultant's report quarterly with Consultant Pharmacist and Medical Director to track and trend data. Direct caregivers (Certified Nursing Assistants), together with the family and care plan team, is involved in the process of developing and implementing effective, person-specific interventions to address behavioral symptoms. If any resident is admitted on an antipsychotic or is started on an antipsychotic after admission, the Consultant Pharmacist, along with the practitioner, reviews that resident's care plan, including all medications, within 24-48 hours. YES NO A documented process is in place and is utilized when initiating an antipsychotic prescription (e.g., standard order set, decision support algorithm, routine monitoring recommendations, etc.). "Yes" answers require supporting documentation and visual confirmation by quality improvement personnel. Developed under the Partnership to Improve Dementia Care in Nursing Homes
PARTNERSHIP TO IMPROVE DEMENTIA CARE IN NURSING HOMES *Questions to Consider in Interdisciplinary Team Review of Individual Dementia Care Cases If the behavioral symptoms represent a change or worsening, was a medical work up performed to rule out underlying medical or physical causes of the behaviors, if appropriate? Were current medications considered as potential causes of the behaviors (i.e., those with significant anticholinergic or other side effects)? If a medical cause (e.g., UTI) was identified, was treatment (if indicated) initiated in a timely manner? If medical causes were ruled out, did the staff attempt to establish the root causes of the behaviors, using a careful and systematic process and individualized knowledge about the resident when possible? Were family caregivers or others who knew the resident prior to his/her dementia consulted about prior life patterns, responses to stress, etc.? Was the initial clinical indication for the medication valid? Were non-pharmacologic, person-centered interventions tried before medications (other than in an emergency)? Were the results documented? Were specific target behaviors identified and desired outcomes related to those behaviors documented? Were caregivers aware of the target behaviors and desired results of the medication? Was the resident or appropriate legal representative consulted about the decision to use an antipsychotic medication and was that discussion documented? If a drug is continued for more than a few weeks, is the original clinical indication still valid (are the behaviors still present)? Is appropriate monitoring in place and is the team aware of the potential side effects? If new symptoms or changes in condition occurred after an antipsychotic medication was started, was medication use considered as a potential cause of a change or symptom? If on a medication, did the pharmacist perform a medication regimen review and identify related signs and symptoms, or did the staff inform the pharmacist if symptoms occurred after the last pharmacist visit? Developed under the Partnership to Improve Dementia Care in Nursing Homes
Partnership to Improve Dementia Care in Nursing Homes State Coalition Provider Question Worksheet (Self-Assessment Tool) Appropriate dementia care includes more than managing individuals with dementiarelated behavior. It also requires minimizing and managing the various factors that maintain overall health and physical stability and optimize function in residents who are often complex and may suffer from multiple chronic conditions. How do caregivers collaborate with practitioners to properly assess behavior carefully and systematically, to help rule out critical underlying causes, including (but not limited to) environmental, functional, and other possibly correctable causes or serious medical conditions such as delirium? Does the facility have detailed process guidance for staff regarding the assessment, documentation, and reporting of all symptoms and changes in condition, including behavior? Are they reviewing and addressing staff performance in these areas, based on individual cases? Direct Caregivers 1. How does staff address behavioral responses by persons with dementia in your facility, such as anxiousness or aggressiveness? 2. Do you know if your facility has policies and procedures in place that you are supposed to follow when a resident with dementia exhibits certain behaviors, or those behaviors worsen? 3. What training have you received about how to care for persons with dementia? a. Who provides the training? b. Do you know what materials are used? c. Does the training give you a chance to practice how you would respond? 4. When a resident with dementia demonstrates certain behaviors such as anxiety or aggression, is he or she given a medication to treat them? a. Do you know whether the team at your facility is trying to reduce the use of these drugs? 5. Are residents and families given information about care options for persons with dementia, including those that do or do not use medications? Leadership- (Nursing Home Administrator, Director of Nursing, Medical Director) 1. How will your facility measure success in improving dementia care and reducing or optimizing antipsychotic drug use? 2. What do you see as the major barriers to accomplishing this?
3. Are you currently reviewing data related to antipsychotic drug use for all residents, including residents that are returning or were recently discharged from an acute care setting? 4. Are there tools/resources/support that would assist you in analyzing and interpreting data? For example, telephone or in-person support from: a. A member of your state nursing home association; b. A consultant; c. A quality improvement organization; d. Other state-based nursing home specialist? 5. If your facility is part of a corporation, does the corporation provide educational materials, clinical support or data analysis related to dementia care and/or antipsychotic drug use? 6. Is staff in all departments educated on person-centered care for individuals with dementia? 7. How is the Consultant Pharmacist involved in the overall care of residents? For example, does the Consultant Pharmacist routinely engage in: a. Data analysis; b. Staff education; c. Routine interaction with residents and/or families? 8. How is the Medical Director involved in the overall care of residents with dementia Developed under the Partnership to Improve Dementia Care in Nursing Homes
PARTNERSHIP TO IMPROVE DEMENTIA CARE IN NURSING HOMES Provider Implementation Flow Diagram Engage leadership team (DON, administrator, medical director, consultant pharmacist) Leadership team meets with direct caregivers to conduct facility self-assessment and establish goals Leadership team and direct caregivers review current policies and procedures related to dementia care Use actual care situations to review caregiver and practitioner performance regarding implementation of desired practices (see questions to consider) Review data an rates of antipsychotic use in the facility Review utilization of antipsychotic medications and other psychopharmacological medications throughout the facility Identify residents who could benefit from modification of their current treatment regimen, including (but not limited to) attempted reduction' of current antipsychotic medications Establish ongoing meetings, rounds or other means of continuous staff engagement at all levels on individualized approaches to care Analyze and trend data regarding both outcomes and underlying processes related to dementia care and to facility-wide systems for review and action Follow up with State partners to share challenges, successes, resources Developed under the Partnership to Improve Dementia Care in Nursing Homes